Information Use of The K10 Assessment Scale

4817.0.55.
001 - Information Paper: Use of the Kessler Psychological Distress Scale in ABS Health Surveys, Australia, 2007-08
4817.0.55.001 - Information Paper: Use of the Kessler Psychological Distress

Scale in ABS Health Surveys, Australia, 2007-08
Latest ISSUE Released at 11:30 AM (CANBERRA TIME) 04/04/2012
Summary
Contents
Introduction
Publication content
Background
Kessler version comparison and inclusion in surveys
Other short form measures

Includes: Mental Health Inventory 5; Short Form 12; General Health Questionnaire 12; Patient Health
Questionnaire 9; Sphere 12 and Beck Depression Inventory
K10 Scoring
Scoring and categorisation methods
Results
Includes: Demographic; Socio-geographic; Self-assessed Health; Mental Health Conditions and K10
Groupings
Conclusion
Bibliography
About this Release

The Kessler Psychological Distress Scale - 10 (K10) is a short dimensional measure of non-specific
psychological distress in the anxiety-depression spectrum,
In Australia, national level information on psychological distress using the K10 was first collected in the
Survey of Mental Health and Wellbeing of Adults (SMHWB) conducted by the Australian Bureau of
Statistics (ABS) in 1997. The K10 was subsequently included in ABS National Health Surveys (NHS) in
2001, 2004-05 and 2007-08, and in the ABS 2007 SMHWB.
This publication provides information on the use of the K10 in ABS health surveys, and analyses K10
scores by a range of characteristics.
http://www.abs.gov.au/ausstats/abs@.nsf/PrintAllPreparePage?[27/05/2017 12:19:14 AM]

4817.0.55.001 - Information Paper: Use of the Kessler Psychological Distress Scale in ABS Health Surveys, Australia, 2007-08
Expanded Contents
CONTENTS
Introduction
Background
K10 Version Comparison
K6 and K10 Comparison
Inclusion of K10 in ABS Surveys
Inclusion of the K5 in ABS Surveys
Inclusion of the K10 in other Australian Surveys
Other Short Form Measures
K10 Scoring
Results
Demographic and socio-geographic factors
Mental health risk factors
Self-Assessed Health
Mental Health Conditions and medication usage
K10 GROUPINGS BY SINGLE SCORES
Conclusion
Bibliography
Introduction
Contents >>
Introduction
INTRODUCTION
In Australia, mental health is a national health priority area, with one in five Australians experiencing a
mental illness in a given year (ABS, 2007; Commonwealth of Australia, 2009). Under collaborative
arrangements such as the Council of Australian Governments (COAG) National Action Plan on Mental
Health and the National Mental Health Policy, the overarching vision and intent for the mental health
system in Australia is one that:
enables recovery, prevents and detects mental illness early and ensures that all Australians
with a mental illness can access effective and appropriate treatment and community support
to enable them to participate fully in the community. (Commonwealth of Australia, 2009)
To achieve this aim, the mental health of the population needs to be accurately measured at a range of
levels, including at the population level. Where health providers and policymakers can accurately track
prevalence rates of mental illness; access and barriers to mental health services; and social inclusion
and participation rates of people with a mental illness, they can direct programs and policies most
effectively.

One method of detecting a possible mental illness or quantifying the mental health and wellbeing of both
individuals and the population is by measuring levels of psychological distress using the Kessler 10
(K10) psychological distress scale. The K10 is a scale designed to measure non-specific psychological
distress, based on questions about negative emotional states experienced in the past 30 days. The K10
instrument is not a diagnostic tool, but an indicator of current psychological distress, where very high
levels of distress may signify a need for professional help. It is also useful for estimating population need
for mental health services.
This paper examines the use of the K10 in Australian Bureau of Statistics (ABS) and other surveys,
looking at variation in scoring and categorising responses. The paper will also discuss the use of the
Kessler 5 (K5) short form in ABS surveys, and notes other short form measures currently used for
mental health screening, including the Kessler 6 (K6).
The paper presents selected demographic characteristics, risk factors, self-reported and diagnosed
mental health conditions and self-assessed health by K10 results, using data from the 2007 Survey of
Mental Health and Wellbeing (SMHWB) and the 2007-08 National Health Survey (NHS).
All data are available electronically from the ‘download’ tab of this publication. In some cases, K10
survey data are also provided by alternative categorisation systems used in Australia by general
practitioners (GPs) and mental health service providers.
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Background
Contents >>
Background
BACKGROUND
The Kessler Psychological Distress Scale was first developed in 1992 by Professors Ron Kessler and
Dan Mroczek, and was originally used in the United States National Health Interview Survey (NHIS)
(Kessler and Mroczek, 1992). Gradually refining an initial set of 45 questions, Kessler and Mroczek were
able to construct two sets of items: a ten item scale (K10); and a six item scale (K6) (see Tables A and
B, below). The Kessler Psychological Distress Scale was published in 1994 (Kessler and Mroczek,
1994), and subsequently revised in 2001.
The K10 questionnaire was developed to yield a global measure of psychosocial distress, based on
questions about people’s level of nervousness, agitation, psychological fatigue and depression in the
past four weeks (Coombs, 2005).
Sensitivity and specificity data indicate that the K10 is appropriate as a screening instrument to identify
likely cases of psychological distress in the community (Andrews and Slade, 2001).
This section contains the following subsection :



Contents >>
Background >>
K10 VERSION COMPARISON

There are two versions of the K10 used in ABS surveys. For the purposes of this paper, they will be
referred to as the ‘1994 version’ and the ‘2001 version’. The 1997 SMHWB and all iterations of the NHS
use the 1994 version of the K10, where the 2007 SMHWB uses the 2001 version.
The differences between the two versions are identified in Table A, and include the reference period (‘4
weeks’ as opposed to ‘30 days’), the use of the word ‘about’ in the follow-on questions and the use of
the word ‘sad’ instead of ‘depressed’.
There is an additional follow-on question (Q8) in the 2001 version, so the 1994 version has the potential
to skip two questions if the respondent answers ‘none of the time’ in selected questions, while the 2001
version has the potential to skip three questions. Follow-on questions are not asked if the respondent
answers ‘none of the time’ in the preceding question.
Table A: 1994 and 2001 K10 version comparison
Q K10 - 1994 version 2001 K10 Q

- 2001, 2004-05 & 2007-08 NHS - 2007 SMHWB
- 1997 SMHWB
In the past 4 weeks: During the past 30 days:
1 about how often did you feel tired out for no 1 about how often did you feel tired out for no
good reason? good reason?
2 about how often did you feel nervous? 2 about how often did you feel nervous?
3 [if not "none of the time"] 3 [if not "none of the time"]
about how often did you feel so nervous that how often did you feel so nervous that
nothing could calm you down? nothing could calm you down?
4 about how often did you feel hopeless? 4 about how often did you feel hopeless?
5 about how often did you feel restless or fidgety? 5 about how often did you feel restless or
fidgety?
6 [if not "none of the time"] 6 [if not "none of the time"]
about how often did you feel so restless you how often did you feel so restless that you
could not sit still? could not sit still?
7 about how often did you feel depressed? 7 about how often did you feel depressed?
8 about how often did you feel that everything 9 about how often did you feel that everything
was an effort? was an effort?
9 8 [if not "none of the time"]
about how often did you feel so sad that nothing how often did you feel so depressed
could cheer you up? nothing could cheer you up?

10 about how often did you feel worthless? 10 about how often did you feel worthless?
K10+
The K10+ includes the 10 question psychological distress scale and sets of additional targeted
questions. The set of additional questions developed by the Harvard School of Medicine include the
frequency of reported feelings, functioning, consultations with healthcare professionals and contribution
of physical health problems (Harvard School of Medicine, 2005).
The 2007 SMHWB includes additional questions that focus on aggressive behaviour, and the Australian
Mental Health Outcomes and Classification Network (AMHOCN) use additional questions that focus on
disability.

Contents >>
Background >>
K6 AND K10 COMPARISON

The K6 is a truncated version of the K10 in which four questions are not used: the ‘tired out for no good
reason’ question, and the three ‘if not none of the time’ questions (see table B, below). Given its shorter
nature, the K6 cannot entirely rely on the validation of the instrument on which it was based. Omitting or
modifying questions from an accepted psychometric instrument may produce a reduction in efficacy.
According to Furukawa et al (2003), the K10 performed marginally better than the K6 in screening for
Composite International Diagnostics Interview (CIDI) and Diagnostic and Statistical Manual for Mental
Disorders, Fourth Edition (DSM-IV) mood and anxiety disorders. However, the K6 is preferred in
screening for DSM-IV mood or anxiety disorders because of its brevity and consistency across
subsamples.
A small validation study carried out in Boston found evidence that the six-question scale is at least as
sensitive as the ten-question scale for the purpose of discriminating between cases and non-cases of
serious mental illness (Harvard School of Medicine, 2005). K6 validation studies were also carried out in
a number of countries throughout the world, which uniformly found that the K6 had very good
concordance with independent clinical ratings of serious mental illness (Kessler et al, 2010). The K6 is
now included in the core of the US National Health Interview Survey (NHIS) and the National Household
Survey on Drug Abuse (Kessler et al, 2002).
Table B: K6
Q K6 – 2001 version 2001 K10 Q

During the past 30 days:
1 about how often did you feel nervous? 2
2 about how often did you feel hopeless? 4
3 about how often did you feel restless or fidgety? 5
4 about how often did you feel so depressed that nothing could cheer you up? 8

5 about how often did you feel that everything was an effort? 9
6 about how often did you feel worthless? 10

Contents >>
Background >>
INCLUSION OF K10 IN ABS SURVEYS

The K10 was first used by the ABS in the 1997 SMHWB, and has continued to be used in the SMHWB
and all National Health Surveys from 2001.
In addition, the 1997 SMHWB employed the Composite International Diagnostic Interview (CIDI) to
diagnose selected mental disorders, including anxiety, affective, and substance use disorders. This
diagnostic tool provided an opportunity to compare short modules included in the survey that measure
mental health, such as the General Health Questionnaire 12 (GHQ12) and the K10.
Analysis of the results from the 1997 SMHWB revealed a strong association between a high K10 score
and a CIDI diagnosis of current anxiety and affective disorders. A lesser, but significant association was
found between the K10 and the presence of any current mental disorder or other mental disorder
categories. The K10 was then selected for inclusion in the 2001 NHS, as the supporting evidence from
the SMHWB analysis showed it to be a better predictor of psychological distress than the other short
general measures of mental health used in the 1997 SMHWB, particularly the GHQ12. This finding was
supported by research from Andrews and Slade (2001).
Soon after the development of the 2001 NHS concluded, the K10 instrument was revised, with the new
version (the 2001 version) becoming generally used in international surveys, including the CIDI
component of the World Mental Health (WMH) Survey Initiative.
As the 2007 SMHWB was based on the WMH-CIDI, the ABS used the 2001 version of the K10 in this
survey. To maintain time series in the NHS, however, and enable ongoing comparison with K5 data from
the National Aboriginal and Torres Strait Islander Health Survey (see below), the 1994 version is used in
the 2004-05 and subsequent NHSs.

Contents >>
Background >>
INCLUSION OF THE K5 IN ABS SURVEYS

The K5 is a subset of questions derived from the K10, which incorporates minor wording changes for
Aboriginal and Torres Strait Islander peoples surveys (see Table C). The questions in the K5 were
refined with a range of experts, including State and Territory health authorities who had used a modified
Kessler scale in other surveys. As for the K6, the K5 is an incomplete and altered version of the K10,
however Professor Kessler was consulted on the modified scale and advised that the K5 provides a

worthwhile short set of psychological distress questions.
The K5 is used in the following ABS surveys:
- the 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS); and
- the 2004-05 and 2011-13 National Aboriginal and Torres Strait Islander Health Survey
(NATSIHS).
Differences between the K5 and the K10 include:
- the use of the word ‘last’ in place of ‘past’ in the question introduction, and
- the use of ‘without hope’ in place of ‘hopeless’, and ‘jumpy’ in place of ‘fidgety’ in the question text
(see Table C below).
Table C: K5 comparison with relevant K10 questions
K5 (based on 1994 version) K10 - 1994 version

In the last 4 weeks: In the past 4 weeks:
1 about how often did you feel nervous? 2 about how often did you feel nervous?
2 about how often did you feel without hope? 4 about how often did you feel hopeless?
3 about how often did you feel restless or 5 about how often did you feel restless or
jumpy? fidgety?
4 about how often did you feel everything was 6 about how often did you feel that everything
an effort? was an effort?
5 about how often did you feel so sad that 7 about how often did you feel so sad that
nothing could cheer you up? nothing could cheer you up?

Contents >>
Background >>
INCLUSION OF THE K10 IN OTHER AUSTRALIAN SURVEYS

The K10 is widely used in a range of Australian government and non-government collections, including:
- the Household, Income and Labour Dynamics in Australia (HILDA) survey;

- the National Drug Strategy Household Survey (NDSHS);
- the National Prisoner Health Census;
- the Australian Mental Health National Outcomes and Casemix Collection (NOCC) measures; and
- State-based population computer assisted telephone interviewing (CATI) health surveys,
including:
- the New South Wales (NSW) Population Health Survey;
- the Victoria (VIC) Population Health Survey;
- the Western Australia (WA) Health & Wellbeing Surveillance System (HWSS);
- the South Australia (SA) Monitoring and Surveillance System (SAMSS); and
- the Queensland (QLD), Northern Territory (NT), Tasmania (TAS) and Australian Capital
Territory (ACT), Smoking, Nutrition, Physical Activity, Stress (SNAPS) surveys.

The ABS Information Paper, Producing National Estimates from State Health Surveys, 2004 (cat. no.
4375.0.55.001), shows comparative K10 results between pooled State Surveys and the 2004-05 NHS.
MEDICARE BENEFITS SCHEDULE

Under the MBS, the K10 is one of the recommended outcomes tools for a GP to use for assessment and
review before referring a patient to allied health professionals (e.g. psychologists) as part of a GP health
management plan (DoHA, 2011). Other tools used include the Short Form 12 (SF-12) and Health of the
Nation Outcome Scales (HoNOS).
INCLUSION OF K10 AND K6 IN INTERNATIONAL SURVEYS

The K10 is used in a series of epidemiological surveys across 27 countries from all regions of the world
as part of the WMH Survey Initiative (Kessler & Ustun, 2004), as well as being used in the Canadian
National Health Interview Survey (NHIS).
As noted above, the K6 is a core measure in the US NHIS and the US National Household Survey of
Drug Abuse.

Contents >>
OTHER SHORT FORM MEASURES

Several other short form survey measures of mental health are used either individually or as part of
larger health instruments. Among the most common are the following measures:
MENTAL HEALTH INVENTORY (MHI-5)

The MHI-5 is part of the Medical Outcome Study 36-item Short-Form (SF-36) Health Survey. It is a five-
item measure of mental health with a time frame of the past four weeks, and has been recommended as
a screening tool for mood, affective and some anxiety disorders (Rumpf et al, 2009). The scale has
performed well in criterion-based tests of validity, with subjects with low scores often requiring inpatient
and outpatient psychiatric care and exhibiting suicidal ideation (Berwick et al, 1991).
SHORT FORM 12 (SF12)

The SF12 is a standard international instrument owned by Quality Metric. It provides a general measure
of health status through twelve questions on:
1. physical functioning;
2. role limitations due to physical health problems;
3. bodily pain;
4. general health;
5. vitality (energy/fatigue);
6. social functioning;
7. role limitations due to emotional problems; and
8. mental health (psychological distress and psychological wellbeing).

All questions use a reference period of four weeks prior to the interview. Mental health represents only
one of a wider range of constructs measured by the SF12. The K10 is preferred over the SF-12 to
estimate mental health because it was designed specifically as a measure of distress, as well as offering
the advantages of easy administration and scoring (Andrews & Slade, 2001).
GENERAL HEALTH QUESTIONNAIRE 12 (GHQ12)

The GHQ was originally developed by Professor David Goldberg in the 1970s as a 60-item instrument to
measure mental health (Goldberg et al, 1997). It now exists in a range of shortened versions including
the GHQ30, the GHQ28, the GHQ20, and the GHQ12. The questionnaire was designed to detect
psychiatric disorders among respondents in community and primary care settings. It is scored using a
four-level response scale assessing the severity of a mental problem over the past few weeks.
Research by Furukawa et al (2003) found that the K6 and K10 have better overall discriminatory power
than the GHQ12 in detecting depressive and anxiety disorders contained in the DSM-IV. Andrews and
Slade (2001) note that the K10 has a larger range of questions along the distress continuum than the
GHQ12. They also note that the GHQ is proprietary and is paid for each time it is used, while the K10 is
in the public domain and may be used without charge.
PATIENT HEALTH QUESTIONNAIRE 9

The Patient Health Questionnaire 9 (PHQ-9) is a nine item depression module developed by Dr Robert
Spitzer, Dr Janet Williams, Kurt Kroenke and colleagues (Kroenke, 2001). The PHQ-9 is an instrument
for the identification of mild, moderate, moderately severe, and severe depression, with questions asked
for a reference period of the last two weeks. While there are similarities between the PHQ-9 and the K10
questions, the PHQ-9 is not widely used in Australian population surveys.
SPHERE-12
The SPHERE-12 is a screening tool for psychological distress, comprising six psychological items and
six somatic/fatigue items with a reference period of ‘the past few weeks’. Beyond Blue identifies the K10
and the SPHERE-12 as checklists to identify depression and anxiety (Beyond Blue, 2012).
BECK DEPRESSION INVENTORY

The Beck Depression Inventory is a clinical depression test that measures the level of depression in
patients with clinical depression. The Beck Depression Inventory Second Edition (BDI–II) was developed
to correspond with the DSM-IV (Beck, Steer & Brown, 1996). The BDI–II consists of 21 items to assess
the intensity of depression in the last two weeks in both clinical and non-clinical settings, rating people
as non-depressed, dysphoric (a state of unease or mental discomfort), and dysphoric or depressed.
Other measures include the:
- Behaviour and Symptom Identification Scale (BASIS-32) (DoHA, 2003);

- Mental Health Inventory 38 (ibid);
- Brief psychiatric rating scale (Overall and Gorham, 1962);
- Beck hopelessness scale (Beck and Steer, 1987);
- Beck anxiety inventory (Beck and Steer, 1990);
- Health of the Nation Outcome Scales (HoNOS) (GPcare, 2012);
- Raskin Depression Scale (Raskin, 1969); and
- Spielberger State Trait Anxiety Scale (Spielberger et al, 1983).

K10 Scoring
Contents >>
K10 Scoring
K10 SCORING
The K10 is scored using a five-level response scale based on the frequency of symptoms reported for
each question. In most ABS and other Australian surveys, 1 is the minimum score for each item (none of
the time) and 5 is the maximum score (all of the time). The sum of these scores yields a minimum
possible score of 10 (all answers were ‘none of the time’) and a maximum possible score of 50 (all
answers were ‘all of the time’) (see Table D).
Table D: K10 Question Scores
Answer Score
none of the time 1
a little of the time 2
some of the time 3
most of the time 4
all of the time 5
Minimum possible score 10
Maximum possible score 50
In the US, the K10 is typically scored using a system where 0 is the minimum score for an answer (none
of the time) and 4 is the maximum score (all of the time), with a possible total minimum score of 0 and
maximum score of 40.
CATEGORISING K10 RESULTS (AUSTRALIA)

While no universally agreed categories or groupings exist for K10 scores, a number of different methods
are used in Australia, depending on the purpose of administration and the setting in which it is delivered.
In ABS surveys, the score groupings and categories of psychological distress were developed drawing
on an amalgam of the work of the Clinical Research Unit for Anxiety and Depression (CRUfAD),
Andrews and Slade (2001), and Korten (submitted). Scores are grouped into four levels of psychological
distress (see Table E, below).
Table E: ABS K10 score groupings and categorisation
K10 Total Score

Score Levels
10-15 Low
16-21 Moderate
22-29 High

30-50 Very high
Note: In the 1997 SMHWB, the scoring algorithm was reversed, so that low scores indicate high levels of
psychological distress and high scores indicate low levels of psychological distress. Users of the 1997
SMHWB Confidentialised Unit Record File (CURF) need to recalculate scores to enable direct
comparisons with other ABS surveys, as follows:
Low distress - 45-50 (normally 10-15)

Moderate distress - 39-44 (normally 16-21)
High distress - 31-38 (normally 22-29)
Very high distress - 10-30 (normally 30-50)
OTHER METHODS OF CATEGORISING

Table F, below, shows K10 score groupings and categories used by CRUfAD and GPcare in primary
healthcare settings to assist in monitoring distress, rather than identifying the presence of a disorder
(Coombs, 2011). This method was also used in the 2001 Victorian Population Health Survey.
Table F: CRUfAD & GPcare score groupings and categorisation
K10 Total Level of psychological distress

Score Levels
10-19 are likely to be well
20-24 are likely to have a mild mental disorder
25-29 are likely to have a moderate mental disorder
30-50 are likely to have a severe mental disorder
Table G shows K10 categories used by specialist mental health services for people who are already in
specialist care. While the score groupings are identical to those used by CRUfAD and GPcare in Table
F, the description for the corresponding level of psychological distress differs.
Table G: Specialist Mental Health Services score groupings and categorisation

Score Levels
10-19 The score indicates that the client or patient may currently not be experiencing
significant feelings of distress.
20-24 The client or patient may be experiencing mild levels of distress consistent with a
diagnosis of a mild depression and/or anxiety disorder.
25-29 The client or patient may be experiencing moderate levels of distress consistent
with a diagnosis of a moderate depression and/or anxiety disorder.
30-50 The client or patient may be experiencing severe levels of distress consistent with
a diagnosis of a severe depression and/or anxiety disorder.
There is also a ‘Plain English’ K10 categorisation, developed with AMHOCN and the Mental Health
Association of NSW for interpreting K10 data in the 2002 Healthy Mind Day questionnaire. In this

system, grouped scores are categorised into three levels of psychological distress, as shown in Table H,
below.
Table H: ‘Plain English’ score groupings and categorisation

Score Levels
10-15 The score reveals that the client or patient may currently not be experiencing
significant feelings of distress.
16-30 The client or patient may be experiencing moderate symptoms of depression
and/or anxiety. These symptoms may be causing some distress in their everyday
life.
31-50 It is likely that the client or patient may be experiencing some form of depression
and/or anxiety.
K6 SCORING & CATEGORISATION

The K6 is scored in the US using the same five-level response scale as the K10, where 0 is the
minimum score for an answer (none of the time) and 4 is the maximum score (all of the time), with a
minimum possible score of 0 and maximum possible score of 24.
Rules for optimal scoring of the K6 screening scale have been identified in Kessler et al (2003 & 2010),
using ‘dichotomous’ (two groupings) and ‘polychotomous’ (multiple groupings) methods. As each scale
item has five response categories and there are six items, the unweighted scale has values in the range
0-24 (US scoring) or 6-30 (Australian scoring). In most applications, based on standard validation
studies, respondents with scores of 13-24 are classified as having a probable serious mental illness and
those with scores of 0-12 as probably not having a serious mental illness (Kessler et al, 2010).
Converted to Australian scoring, categories are as follows:
Table I: K6 Dichotomous score groupings and categorisation
Australian K6 Level of psychological distress

Total Score Levels
6-18 No probable serious mental illness
19-30 Probable serious mental illness
The second method is a polychotomous scoring method where the K6 score groupings are refined into
strata that differentiate between levels of serious mental illness (Kessler et al, 2010). Using Stratum-
Specific Likelihood Ratio (SSLR) analysis, individual K6 scores are transformed into a score that
represents the predicted probability of that person having a serious mental illness (Kessler et al, 2010;
Furukuwa et al, 2003). Strata are shown using Australian scores in Table J, below.
Table J: K6 Polychotomous score groupings
Australian K6
Total Score Levels
6

7-13
14-18
19-24
25-30
Results
Contents >>
Results
RESULTS
The following section of the paper presents characteristics and experiences that may affect mental
health, including:
- demographic and geographic characteristics;

- personal and financial stressors;
- life experiences;
- self-assessed mental and physical health;
- quality of life;
- mental health conditions; and
- unmet need for mental health services.
Data is analysed by K10 results to demonstrate the relationships between each of these characteristics
and levels of psychological distress – that is, the potential for each of these characteristics to vary
according to levels of distress.
The paper then explores K10 results by selected mental health disorders (both self-reported and as
diagnosed by the CIDI); suicidal thoughts or behaviours; and mental health service usage and
strategies.
Analyses generally include moderate, high and very high levels of psychological distress.
The K10 module was asked of persons aged 18 and over in the NHS, and persons aged 16-85 years in
the SMHWB. In this paper, SMHWB data is presented for people aged 18-85 for consistency purposes.
When comparing results from the NHS and SMHWB, it is important to note differences in purpose,
scope and design of these two surveys. For example, the NHS was designed to obtain national
benchmarks on a wide range of health issues, and to enable changes in health to be monitored over
time, while the SMHWB (a voluntary survey) was designed to provide information on the prevalence of
three major mental health disorder groups in the population (anxiety, affective and substance use
disorders). The sample, response rate and enumeration period were also different within iterations and
across each of the surveys (see Table L).
Table L: NHS (2001, 2004-05 & 2007-08) & SMHWB (1997 & 2007)

Survey Sample Age in scope Response Enumeration period

Rate
1997 SMHWB 10,600 Adults 18 years and over 78% May - Aug 97 (4m)
2007 SMHWB 8,800 Adults 16-85 years 60% Aug - Dec 07 (5m)
2001 NHS 26,900 Adults 18 years and over 92% Feb - Nov 01 (10m)
2004-05 NHS 25,900 Adults 18 years and over 90% Aug 04 - Jun 05 (11m)
2007-08 NHS 20,800 Adults 18 years and over 91% Aug 07 - Jun 08 (11m)
This section contains the following subsection :


Contents >>
Results >>
DEMOGRAPHIC AND SOCIO-GEOGRAPHIC FACTORS

Data for demographic and socio-geographic factors is drawn from the 2007-08 NHS.
Age
In 2007-08, most Australians aged 18 and over (67%) reported low levels of psychological distress.
Around one fifth (21%) reported moderate levels of distress, 8.5% reported high levels and 3.5%
reported very high levels of psychological distress (see datacube table 1 for more detail).
Sex
Women generally reported higher levels of psychological distress than men, with 14% of women having
high or very high levels of distress and 23% having moderate levels of distress, compared with 9.6% and

19% for men, respectively (see datacube table 2 for more detail).
Over the past decade, rates of high and very high levels of psychological distress have followed a similar
pattern, with women having consistently higher levels of distress than men (see Graph 3, below).
K5 age and sex results

The 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS) showed that over 30%
of Aboriginal and Torres Strait Islander people aged 18 years and over had experienced high or very
high levels of psychological distress in the last four weeks, more than twice the rate of the general
population (12%). Community surveys using the K5 show similar results. Across a number of community
surveys drawn together for analysis (Jorm et al, 2012), the Aboriginal and Torres Strait islander
population had a higher prevalence rate of high or very high psychological distress scores for both sexes
and all adult age groups.
Socio-geographic characteristics
After adjusting for age, data showed that while levels of psychological distress vary little according to
State/Territory or remoteness (see datacube tables 3 and 4), they were related to socio-economic
factors as measured by the Socio-Economic Index of Areas (SEIFA) Index of Relative Disadvantage. In
2007-08, people who lived in areas of most disadvantage had significantly higher levels of psychological
distress than people who lived in areas of least disadvantage. Just under one in five people who lived in
the most disadvantaged areas had high or very high levels of distress (19%), compared with 9.3% of
people in the least disadvantaged areas (see Graph 4, below, and datacube table 5).


Contents >>
Results >>
MENTAL HEALTH RISK FACTORS

There are a number of personal and financial factors, events or experiences that can influence a
person’s level of psychological distress. The NHS and the SMHWB collected information on a range of
risk factors for mental health experienced either in a person’s lifetime or in the past twelve months. While
some of these may have taken place well before the K10 reference period of four weeks, ABS data
shows a strong association between selected factors and high levels of psychological distress. This may
suggest that the psychological effects of particular experiences endure for long periods of time.
Personal stressors
The NHS asks about a range of stressors that a person or their close friends or family may have
experienced in the past year, including:
- marriage breakups;
- the death of a family member or friend;
- a serious illness or accident;
- alcohol or drug related problems;
- mental illness;
- serious disability;
- loss of job or being unable to get a job;
- being a witness to/victim of abuse or violence;
- trouble with the police; or
- gambling problems.
In 2007-08, people who had experienced any of the stressors identified above were more likely to
experience psychological distress than people who had not experienced personal stressors. The highest
levels of psychological distress were experienced by people with a serious disability, (including people
who identified a family member or close friend with a serious disability). One third of these people (33%)
experienced high or very high levels of psychological distress, almost five times higher than people who
said they had no personal stressors (7%). Around 30% of people who had trouble with the police in the
past year reported high or very high levels of distress, followed by 29% of people affected by a gambling

problem. For more detail, see datacube table 6.
From this point, data is drawn from the 2007 SMHWB.
Financial stressors
The SMHWB collected information on a range of financial stressors that a person may have experienced
at any time in the past year, including where they:
- could not pay bills on time;

- pawned or sold something;
- went without meals;
- were unable to heat their own home;
- sought assistance from welfare or community organisations; or
- sought financial assistance from friends or family.
In 2007, people aged 18-85 years who had experienced financial stressors in the past year were more
likely to have higher levels of psychological distress than those who reported no financial stressors (see
datacube table 7).
Just under half the people who said they could not afford to heat their home at some time in the past
year had high or very high levels of psychological distress (48%), while 44% of people who had gone
without meals and 43% of people who had sought assistance from welfare or community organisations
also had high or very high levels of distress.
Life experiences (homelessness, incarceration and serving in the defence force)

Life experiences can influence a person’s level of psychological distress, particularly if they are negative
experiences. In 2007, over 470,000 people between 18 and 85 years of age reported having been
homeless at some point in their lives (see datacube table 8). Of these people, 38% had high or very high
levels of psychological distress, over four times higher than those who had never been homeless (8.5%).
In 2007, people who had spent time in gaol or incarcerated at some point in their life were more likely to
report high or very high levels of psychological distress (25%) than those who had not been incarcerated
(9%). In 2010, around 29% of people awaiting entry into prison also showed high or very high levels of
psychological distress (AIHW, 2010).
Contents >>
Results >>
SELF-ASSESSED HEALTH
Perception of quality of life

In the 2007 SMHWB, people were asked how they felt about their lives as a whole, taking into account
what had happened in the last year and what they expected to happen in the future (the Australian
Assessment of Quality of Life instrument). In general, people who perceived the quality of their life to be
generally good showed lower levels of psychological distress than those who felt it to be poor.
In 2007, over half the population aged 18-85 (51%) said they were delighted or pleased with the quality

of their lives and of these people, less than 3% had high or very high levels of psychological distress. In
comparison, 75% of people who perceived their quality of life to be unhappy or terrible had high or very
high levels of psychological distress. Almost a third of people who thought the quality of their lives was
mixed (both good and poor) had high or very high levels of psychological distress (29%) - over three
times higher than the national average of 9.4% (see datacube table 9).
Self-assessed mental health

People were also asked to rate their mental health on a five-point scale from excellent to poor. In 2007,
over 10 million people aged 18-85 years rated their overall mental health as excellent or very good. Of
these people, 3% had high or very high levels of psychological distress in the past four weeks, which
was significantly lower than people who assessed their mental health as fair or poor (50%). Interestingly,
people who assessed their mental health as fair or poor were almost equally distributed among the four
K10 categories, with 20% having very high levels of distress, 30% having high levels, 29% having
moderate levels, and 21% having low levels (see datacube table 10).
Self-assessed physical health

Patterns of psychological distress were similar for people who rated their physical health as good or
better. Not surprisingly, however, the relationship between physical health and K10 outcomes was not
as marked as that between mental health and K10 outcomes, with far less people who rated their
physical health as fair or poor having high or very high levels of distress than people who rated their
mental health as fair or poor (27% compared with 50% - see Graph 5, below, and datacube table 11 for
more detail).

Contents >>
Results >>
MENTAL HEALTH CONDITIONS AND MEDICATION USAGE

The following analyses examine the presence of selected mental health disorders or experiences for
people with moderate, high or very high levels of psychological distress.
Mental health disorders

In the SMHWB, the presence of a mental health disorder at some time in a person's lifetime was

diagnosed by the World Health Organization (WHO) Composite International Diagnostic Interview
(CIDI). Disorders were classified as having symptoms in the last 30 days and the last 12 months. The
NHS collected current, self-reported mental or behavioural conditions that had lasted or were expected
to last six months or more. In both surveys, people with moderate, high or very high levels of
psychological distress in the past four weeks were far more likely to have an affective, anxiety or
substance use disorder than people with low distress.
In the 2007 SMHWB, around 66% of people who experienced very high levels of distress in the last four
weeks were diagnosed by the CIDI to have a mental disorder with symptoms in the last 30 days, and
almost four out of every five people with very high levels of distress had a mental disorder with
symptoms in the last 12 months (79%). For people with high levels of distress in the past four weeks,
42% had a current mental disorder (30 day symptoms), and 58% had experienced symptoms in the last
12 months (see datacube table 12a and 12b for more detail).
People with very high levels of distress were the most likely to have anxiety (54%), affective (34%) or
substance use disorders (9.4%) with symptoms in the previous 30 days, followed by people with high
levels of distress (32%, 15% and 6.6% respectively). Graph 6 shows levels of psychological distress by
the presence of these mental health disorders (see datacube tables 13a to 15b for more detail).
In the 2007-08 NHS, people with moderate, high and very high levels of psychological distress were also
far more likely to self-report a mental or behavioural disorder than people with low levels of distress.
Around 21% of people with very high levels of distress reported an anxiety disorder, 63% reported an
affective disorder, and 5.4% reported a substance use disorder (see graph 7 below and datacube table
16 for more detail).

Suicidal thoughts or behaviour

In 2007, there were over 360,000 people who had suicidal thoughts or had planned or attempted suicide
in the last 12 months (see datacube table 17). People with very high levels of psychological distress
were over ten times more likely to have had suicidal thoughts or behaviours in the last 12 months than
the national average (25% compared with 2.3%), and people with high levels of distress were over five
times more likely (13%).
Services and strategies used for mental health

In 2007, 1.8 million people accessed services for mental health in the past 12 months (including
treatment in a hospital), 1.8 million consulted a health professional, and over 2 million people sought
support from family or friends. Other services and strategies for mental health collected in the SMHWB
include:
- being admitted overnight or longer to hospital;

- using internet group/chat room/self-help sites;
- participating in group/phone counselling;
- increasing level of exercise or physical activity; and
- using alcohol or drugs.
Around 44% of people with high or very high levels of distress accessed services or saw a health
professional for mental health in the past 12 months. While 27% of people with high or very high distress
levels increased their physical activity to improve their mental health in this time, 18% used alcohol or
drugs (see datacube tables 18a and 18b for more detail).
Medication usage
In general, people high or very high levels of psychological distress were more likely to take medication
for mental health than the general population (47% compared with 12%). People with very high levels of
distress were the most likely to take medication (see datacube table 19 for more detail). The most
common types of medication taken by people with high or very high levels of distress were anti-
depressants and sleeping pills.
Unmet need
People whose need for mental health services were only partially met in the last 12 months were more
likely to have high or very high levels of psychological distress than people whose needs were fully met
(46% compared with 25%)(see datacube table 20 for more detail).

Contents >>
Results >>

Datacube table 21 presents data for responses to individual K10 questions in the 2007-08 NHS (using
the 1994 version of the K10). People who responded ‘none of the time’ to Q2 and Q5 were automatically
coded in Q3 and Q6 to ‘none of the time’, which means that responses in this category include people
who did not answer the question, as well as those who did. Table 21 has an additional column for Q3
and Q6, which only includes people who were actually asked questions 3 or 6 (i.e. did not answer ‘none

of the time’ to Q2 and Q5).
A few of the key findings for responses to individual questions are summarised below:
- Around 11% of adults aged 18 years and over reported that they felt tired out for no good reason
most or all of the time in the past four weeks (Q1). This question had more responses than any of
the other K10 questions of most or all of the time, followed by feeling that everything was an effort
(Q8) with 7.4%.
- 6.5% of people 18 years and over felt restless or fidgety most or all of the time. Of the people
who answered they felt restless or fidgety at least a little of the time, 6.4% felt so restless that they
could not sit still most or all of the time.
- 5.2% felt nervous most or all of the time in the past four weeks. Of the people who answered they
felt nervous at least a little of the time, 2.8% felt so nervous that nothing could calm them down
most or all of the time.
- 2.6% of Australian adults felt hopeless or worthless most or all of the time in the last four weeks.
- 4% of Australian adults felt depressed most or all of the time in the last four weeks, and 2.1% felt
so sad most or all of the time that nothing could cheer them up.
Conclusion
Contents >>
Conclusion
CONCLUSION
This paper provides information on the use of the Kessler 10 Psychological Distress Scale (K10) as an
indicator of psychological distress, and its relationship to other measures of wellbeing. By providing
information about the association of levels of distress with socio-economic factors and life experiences,
as well as the relationship between distress and self-reported and diagnosed mental health disorders,
this paper adds to the research on the use of this scale in an Australian setting.
Additional research on the use of short form Kessler scales is planned to further inform use of this
measure.
Bibliography
Contents >>
Bibliography
BIBLIOGRAPHY
ABS Publications
Year Publication Category No.

1997 Mental Health and Wellbeing: Profile of Adults, Australia (cat. no. 4326.0)
2001 Information Paper: Use of the Kessler Psychological Distress Scale (cat. no. 4817.0.55.001)
in ABS Health Surveys, Australia
2001 National Health Survey: Summary of Results (cat. no. 4364.0)
2004 Producing National Estimates from State Health Surveys (cat. no. 4375.0.55.001)
2004-05 National Aboriginal and Torres Strait Islander Health Survey (cat. no. 4715.0)
2004-05 National Health Survey: Summary of Results (cat. no. 4364.0)
2007 National Survey of Mental Health and Wellbeing: Summary of (cat. no. 4326.0)
Results
2007-08 National Health Survey: Summary of Results (cat. no. 4364.0)
2008 National Aboriginal and Torres Strait Islander Social Survey (cat. no. 4714.0)
2010 The Health and Welfare of Australia's Aboriginal and Torres Strait (cat. no. 4704.0)
Islander Peoples
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Previous Page
History of Changes
This document was added 12/07/2012.
12/07/2012 - Broken links have been fixed and some minor formatting changes applied.
Explanatory Notes
Glossary
Adjusting for age Age standardisation is used in this publication to remove the effects of age
when comparing populations with different age structures. For example, when looking at the labour force
status of people in disadvantaged areas, it can be seen that more people in these areas are not in the
labour force (compared with more advantaged areas). However, the age distribution of people in
disadvantaged areas is skewed towards the higher age groups (that is, older people are more likely to
live in these areas than younger people), so this higher number could be due to the fact that there are
more older people in the disadvantaged areas, as there are less older people in the work force. Age
standardising removes age from the picture so it can be seen whether there is a correlation between
disadvantage and labour force status independent of age.
The age composition of the 2001 estimated resident population of Australia is used as the benchmarking
population.
Affective Disorders are disorders that involve mood disturbance. Examples include bipolar affective
disorder, depressive episode and dysthymia.
Anxiety Disorders involve feelings of tension, distress or nervousness. Examples include panic
disorder, social phobia, agoraphobia, generalised anxiety disorder (GAD), post-traumatic stress disorder
(PTSD) and obsessive-compulsive disorder (OCD).
Australian Assessment of Quality of Life is an instrument used to measure the burden of disease.
Questions measure illness, independence, social relationships, physical senses, and psychological
wellbeing.
The Australian Mental Health Outcomes and Casemix Collection K-10+ measure adds four
questions to the K10 module which rate degree of disability. These additional questions do not
contribute to the K10 score.
COAG - Council of Australian Governments

Composite International Diagnostic Interview (CIDI) - a comprehensive modular interview which can
be used to assess lifetime and 12-month prevalence of selected mental disorders through the
measurement of symptoms and their impact on day-to-day activities. For more information, see [link]
CRUfAD - Clinical Research Unit for Anxiety and Depression
Depression A mood state characterised by a sense of inadequacy, a feeling of despondency, a

decrease in activity or reactivity, pessimism, sadness and related symptoms. Depending upon the
number and severity of the symptoms, a depressive episode may be specified as mild, moderate or
severe.
DSM-IV - Diagnostic and statistical manual for mental disorders (fourth edition). The DSM-IV is a
handbook for mental health professionals that lists different categories of mental disorders and the
criteria for diagnosing them. The DSM-IV focuses on clinical, research and educational purposes,
supported by an extensive empirical foundation.
GPcare is a website that was developed to meet the needs of general practitioners who were enrolling
in the Better Outcomes in Mental Health Initiative of the Australian Government. It is a way to provide a
common framework for the work of professional groups as they treat people with the common mental
disorders.
Healthy Mind Day was held on 11 April 2002 to raise awareness of depression and anxiety in NSW,
and was conducted by the Mental Health Association of NSW in conjunction with the Pharmacy Guild of
Australia (NSW Branch).
Hierarchy rules In the CIDI, the classification system for some of the mental disorders contains
diagnostic exclusion rules so that a person, despite having symptoms that meet diagnostic assessment
criteria, will not meet criteria for particular disorders because the symptoms are believed to be
accounted for by the presence of another disorder. In these cases, one disorder takes precedence over
another. These exclusion, or ‘hierarchy’ rules are built into the diagnostic algorithms. The ‘with hierarchy’
version of a diagnosis will therefore exclude cases where symptoms have been established for another
disorder for the same time period.
The Household, Income and Labour Dynamics in Australia survey (HILDA) is funded by the
Department of Families and Housing, Community Services, Indigenous Affairs and conducted by the
Melbourne Institute of Applied Economic and Social Research at the University of Melbourne. It collects
information about economic and subjective well-being, labour market dynamics and family dynamics.
K5 A five item measure of psychological distress used by the ABS in Aboriginal and Torres Strait
Islander population surveys.
K6 A 6 question short form of the K10.
K10 The Kessler 10 question psychological distress scale.
Mental disorder According to the ICD-10 (International Classification of Disease - 10th revision)
classification of mental and behavioural disorders, a disorder implies 'the existence of a clinically
recognisable set of symptoms or behaviour associated in most cases with distress and with interference
with personal function (WHO 1992, p 5). Most diagnoses require criteria relating to severity and duration
to be met.

The National Drug Strategy Household survey is funded by the Department of Health and Ageing and
conducted by the Australian Institute of Health and Welfare. It collects information on smoking, alcohol
and drug use of Australians aged 14 years and over.
The National Prisoner Health Census is conducted by the Australian Institute of Health and Welfare.
K10 results are published in The health of Australia’s prisoners, 2009 and 2010.
Prevalence The total number of cases of a disease in a given population at a specific time.
Psychosis A generic psychiatric term for a mental state often associated with the onset of psychotic
symptoms such as delusions, hallucinations, and perceptual disturbances, and by the severe disruption
of ordinary behaviour.
Sensitivity is a measure of how likely it is for a test to pick up the presence of a disease in a person
who does have the disease. An ideal test will have a high sensitivity, meaning it will catch all people with
the disease. Sensitivity is calculated by the following formula: True positives/True positives+False
negative.
Specificity is a measure of how likely it is for a test to pick up the fact that a person does not have a
disease when they are disease free. 100% specificity means a test will not predict anyone from a healthy
group as sick. The formula for specificity is: True negative/true negative+False positive.
Significance testing is performed for a comparison between estimates to determine whether the
difference between corresponding population characteristics is real (given the fact that estimates might
have varied by chance because only a sample of persons was included in a survey). The extent of this
variance is indicated by the standard error (SE). The SE of the difference between two corresponding
estimates (x and y) can be calculated using the following formula:
This standard error is then used to calculate the following test statistic:
If the value of this test statistic is greater than 1.96 then there is evidence, with a 95% level of
confidence, of a statistically significant difference in the two populations with respect to that
characteristic. Otherwise, it cannot be stated with confidence that there is a real difference between the
populations.
Somatic Relating to the body, or pertaining to the body as distinguished from the mind or psyche.
Stratum-Specific Likelihood Ratio (SSLR) is a method that begins with estimates of sensitivity and
specificity for each stratum and estimates predicted probability of a characteristic based on external
assumptions about prevalence in the population of interest (Guyatt and Rennie, 2001).
Substance Use Disorder includes harmful use of and/or dependence on drugs and/or alcohol.
The World Mental Health Survey Initiative is a project of the Assessment, Classification, and

Epidemiology Group at the World Health Organization. The project is coordinating the implementation
and analysis of general population surveys of mental, substance use, and behavioural disorders in
countries in all WHO Regions, with the aim of obtaining accurate cross-national information about the
prevalences and correlates of these disorders.
© Commonwealth of Australia
All data and other material produced by the Australian Bureau of Statistics (ABS) constitutes Commonwealth copyright administered by the ABS. The ABS reserves the
right to set out the terms and conditions for the use of such material. Unless otherwise noted, all material on this website – except the ABS logo, the Commonwealth
Coat of Arms, and any material protected by a trade mark – is licensed under a Creative Commons Attribution 2.5 Australia licence

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4817.0.55.

4817.0.55.001 - Information Paper: Use of the Kessler Psychological Distress

Other short form measures

About this Release

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This section contains the following subsection :

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Inclusion of the K10 in other Australian Surveys

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K10 Version Comparison

K10 VERSION COMPARISON

Table A: 1994 and 2001 K10 version comparison

Q K10 - 1994 version 2001 K10 Q

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K6 and K10 Comparison

K6 AND K10 COMPARISON

Q K6 – 2001 version 2001 K10 Q

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Inclusion of K10 in ABS Surveys

INCLUSION OF K10 IN ABS SURVEYS

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Inclusion of the K5 in ABS Surveys

INCLUSION OF THE K5 IN ABS SURVEYS

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worthwhile short set of psychological distress questions.

The K5 is used in the following ABS surveys:

Differences between the K5 and the K10 include:

Table C: K5 comparison with relevant K10 questions

K5 (based on 1994 version) K10 - 1994 version

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Inclusion of the K10 in other Australian Surveys

INCLUSION OF THE K10 IN OTHER AUSTRALIAN SURVEYS

- the Household, Income and Labour Dynamics in Australia (HILDA) survey;

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MEDICARE BENEFITS SCHEDULE

INCLUSION OF K10 AND K6 IN INTERNATIONAL SURVEYS

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Other Short Form Measures

OTHER SHORT FORM MEASURES

MENTAL HEALTH INVENTORY (MHI-5)

SHORT FORM 12 (SF12)

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GENERAL HEALTH QUESTIONNAIRE 12 (GHQ12)

PATIENT HEALTH QUESTIONNAIRE 9

BECK DEPRESSION INVENTORY

Other measures include the:

- Behaviour and Symptom Identification Scale (BASIS-32) (DoHA, 2003);

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Table D: K10 Question Scores

CATEGORISING K10 RESULTS (AUSTRALIA)

Table E: ABS K10 score groupings and categorisation

K10 Total Score

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30-50 Very high

Low distress - 45-50 (normally 10-15)

OTHER METHODS OF CATEGORISING

Table F: CRUfAD & GPcare score groupings and categorisation

K10 Total Level of psychological distress